|Year : 2012 | Volume
| Issue : 2 | Page : 96-100
The value of ultrasound in the management of blunt abdominal trauma in Zaria, Nigeria
Jerry G Makama1, Ekundayo S Garba1, Istifanus A Joshua2
1 Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika, Nigeria
2 Department of Surgery, University Health Services, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||3-Apr-2013|
Jerry G Makama
Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika Zaria
Source of Support: None, Conflict of Interest: None
Background: Abdominal ultrasound has assumed a major role in the management of blunt abdominal trauma. The aim of the study is to evaluate the role and vile of the use of ultrasonography in screening for blunt abdominal trauma in an emergency setting of a tertiary hospital in Nigeria.
Materials and Methods: It is a retrospective study at a university hospital Zaria. All patients who presented with blunt abdominal trauma from 2008 to 2010 were reviewed retrospectively, using patients' case notes, ultrasonographic findings, operating theatre log books, and surgical audit data. Abdomino-pelvic ultrasound findings of all the patients were noted and compared with actual findings at operation followed by the analysis of the sensitivity and specificity of the ultrasound including positive predictive value and negative predictive value. The grade and experience of the principal Ultrasonographer were also noted.
Results: In a total of 107 patients, 94 (87.8%) were males and 13 (12.14%) were females. The mean age was 33.4 ± 17.42 year (range 2-69). With the ultrasound, positive findings were present in 44 (41.1%) patients while negative findings in 2 (1.9%). Of these positive ultrasound findings, 18 (16.8%) had free intra-abdominal fluid only, 13 (12.1%) had both free intra-abdominal fluid and intra-abdominal organ injury, and 13 (12.1%) had intra-abdominal organ injury only. The major organs with injury included liver 18 (5.2%), spleen 16 (4.7%), stomach or bowel injury 6 (1.7%), and kidney or urinary bladder 3 (0.9%). The sensitivity of ultrasonography was 95.7%, while its specificity was 92%. The positive predictive value was 90% and the negative predictive value was 96.7%.
Conclusion: Ultrasonography is an accurate and safe method for managing patients with blunt abdominal trauma.
Keywords: Abdominal trauma, blunt, ultrasonography, vanity, vile
|How to cite this article:|
Makama JG, Garba ES, Joshua IA. The value of ultrasound in the management of blunt abdominal trauma in Zaria, Nigeria. Arch Int Surg 2012;2:96-100
|How to cite this URL:|
Makama JG, Garba ES, Joshua IA. The value of ultrasound in the management of blunt abdominal trauma in Zaria, Nigeria. Arch Int Surg [serial online] 2012 [cited 2019 Sep 21];2:96-100. Available from: http://www.archintsurg.org/text.asp?2012/2/2/96/110026
| Introduction|| |
Ultrasonography (USS) for blunt abdominal trauma (BAT) was first described in 1971,  and it is currently growing rapidly as a primary screening examination for BAT in most trauma centers of the regions in the world. ,, Evaluation of patients who have sustained BAT may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. While a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is evidence to support that ultrasound (US) in BAT is an extension of the physical examination. The effect of altered level of consciousness as a result of neurologic injury, alcohol or drugs, is another major confounding factor in assessing BAT. The aim of the study is to evaluate the role and the drawback of the use of USS in screening for BAT in an emergency setting of a tertiary hospital in Nigeria.
| Materials and Methods|| |
This was a retrospective study done at Ahmadu Bello University Teaching Hospital Shika Zaria. All patients, regardless of age that presented with BAT from January 2008 to December 2010, were reviewed retrospectively, using patients' case notes, ultrasonographic findings, operating theatre log books, and surgical audit data. Confirmatory diagnosis of BAT was based on clinical evidence of BAT and intra-operative findings at exploratory laparotomy. Intra-operative findings such as evidence of pre-peritoneal hematoma, peritoneal bruise or tear, free fluid or blood in the peritoneal cavity including the pelvis, intra-abdominal organ injury, retroperitoneal hematoma and/or organ injury following BAT were considered "confirmed BAT." Abdomino-pelvic US findings of all the patients were noted and compared with actual findings at operation. Those who were already operated or had penetrating injuries or burns were excluded. The presence and volume of free fluid within the abdominal cavity was accepted as a positive sign for hemaperitoneum. Visceral organs were evaluated for parenchymal injuries consisting of intraparenchymal hematomas, lacerations, and evidence of shattered organ. Other investigations performed included diagnostic peritoneal larvage (DPL), biochemical, and haematological assessments. CT scan was never done in any of the patients due to urgency required for further operative care. Data collected included demographic characteristics, clinical and ultrasonographic findings, and intra-operative findings of patients. The type of ultrasonographic machine used, the probe, the grade and experience of the principal ultrasonographer were also noted.
| Results|| |
A total of 109 patients were admitted with an initial diagnosis of BAT, during the study period. Those with associated chest trauma, postoperative patients, and burns patients were excluded. Only 107 patients satisfied inclusion criteria. Vehicular accident was the most common cause of blunt abdominal injury [Figure 1]. All the patients had US done on them by different consultant radiologists 48 (44.9%) and radiologists in training at the level of registrar 18 (16.8%) and senior registrar 41 (38.3%). In a total of 107 patients, 94 (87.86%) were males and 13 (12.14%) were females. The mean age was 33.4 ± 17.42 years (range 2-69). Ninety seven (55.8%) patients had their USS done within first 24 hours of accident, while 22 (12.6%) patients delayed seeking medical help for a variable number of days (2 days to 1 week). The reasons for delay was (1) gradual development of abdominal symptoms in a patient 11 (6.3%), (2) absence of an ultrasonographer 3 (1.7%), lack of A/E staff commitment 7 (4.0%), and faulty US machine 1 (0.6%). The mean duration of experience of the ultrasonographer was 2.3 years ranging from 1 year to 23 years. They all had US using a 3.5/5.0-MHz convex probe on Aloka Doppler US Machine (Model: SSD-5500).
With the US, free intraperitoneal fluid or organ injuries were present in 44 (41.1%) patients, while they were absent in 2 (1.9%). Of these positive US findings, 18 (16.8%) had free intra-abdominal fluid only, 13 (12.1%) had both free intra-abdominal fluid and intra-abdominal organ injury, and 13 (12.1%) had intra-abdominal organ injury only [Figure 2].
The major organs with injury [Table 1] included liver 18 (5.2%), spleen 16 (4.7%), stomach/bowel injury 6 (1.7%), kidney/urinary bladder 3 (0.9%). Real-time USS was the interventional agent used [Table 2] and using a 2 × 2 contingency table [Table 3] sensitivity and specificity including the positive predictive value and negative predictive value were the predictors of clinical outcome. The sensitivity of USS was 95.7%, while its specificity was 92%. The positive predictive value was 90% and the negative predictive value was 96.7%.
| Discussion|| |
Patients with BAT  present a special challenge to the surgeons. Physical examination is inaccurate in detecting organ injury even if the patient is awake. Frequent co-existence of head injury exacerbates this problem. Duplex sonography allows derivation of Doppler-signal curves in color. The direction of flow is indicated by blue or red, according to flow from or to the probe. This permits a rapid investigation and yields intelligible images. With the color Doppler imaging technique, peripheral parenchymal vessels can be studied, which is of great use in the diagnosis of tumors and in cases of abdominal  trauma. The efficacy and effectiveness of US in evaluating patients suspected of having BAT are near that of computed tomography (CT) and DPL. 
US is used worldwide to evaluate patients with BAT. Sometimes referred to as an extension of the physical exam, US can rapidly help distinguish patients with injury requiring CT or surgery (typically 5-10%) from those with no abdominal injury (>90%). , US has several advantages in the setting of  trauma. It is portable, integrates easily into the resuscitation of trauma victims without causing delay in therapy, is noninvasive, and has no associated morbidity. Limitations of US include its dependence on operator skill and technique, poor image quality in patients with morbid obesity or extensive subcutaneous gas, limited visualization of the retroperitoneum, and less reliable localization of visceral injury compared to CT , Successful use of abdominal US in the setting of trauma can be maximized with adequate sonographer training, appreciation of technical limitations, and adherence to an appropriate trauma US protocol. 
Recently, American surgeons reconsidered USS in trauma and codified its use into FAST (Focused Assessment for the Sonographic examination of the Trauma patients). The goal is to detect hemoperitoneum and pericardial effusion. Advantages are remarkable: US is cost-effective, fast, non-invasive, can be performed by surgeons even on unstable patients. FAST , is now included in the ATLS framework for examination of thoraco-abdominal trauma. In the trauma setting, the Focused Assessment for the Sonographic examination of the Trauma patient (FAST) accurately detects hemoperitoneum. Currently, only an approximate evaluation of the volume of free intraperitoneal fluid (FIPF) can be done by imaging modalities such as US. 
Cost data and time to disposition were determined for analysis. The sensitivity (95.7%), specificity (92%), and accuracy  of US were similar to those reported (sensitivity: 88%, specificity: 100%) in previous studies. There was a significant difference in time to disposition with the US group being significantly lower (P = 0.001). The total procedural cost was 2.8 times greater for the CT/DPL group than for the US group.  US is not only effective in diagnosing BAT, but it is also more efficient and cost-effective than is CT/DPL. Emergency US in patients with abdominal trauma has become a routine diagnostic exam thanks to both its high reliability and its short acquisition time. US allows the overall evaluation of the patient, relative to both the localization of even very small fluid collections and the evaluation of traumatic changes in parenchymatous abdominal organs, especially the spleen which is often injured.  In addition, US has advantages over DPL in the detection of intraperitoneal organ injuries with or without concomitant free intraperitoneal fluid, retroperitoneal injuries, and intrathoracic injuries. Is there any correlation between the amount of free intraperitoneal fluid collection and the need for operative intervention in BAT? The present study has showed that US is inaccurate in detecting solid intra-abdominal injuries; however, it is reliable in detecting FIPF produced as a result of intra-abdominal organ injuries and retroperitoneal organ injuries. We suggest the use of US as the objective initial evaluation method of choice on a routine basis. ,, It has been suggested that DPL is now obsolete in UK hospitals with access to either skilled USS or emergency physician or surgeon-performed focused abdominal sonography in trauma. We believe that abdominal US should be considered an important tool and an integral part in the work-up of major abdominal trauma victims.
There is a growing body of literature pertaining to the use of US in the evaluation of patients with BAT. Multiple studies have looked at the use of this modality as a screening examination for the detection of intra-abdominal fluid and as a means of diagnosing specific organ injuries. , Although US has been used extensively in Europe and Asia, it has only recently been used in the United States. In many centers, US is now being performed by emergency medicine physicians and trauma surgeons as part of the initial trauma evaluation. 
The purpose of this study was to evaluate the efficacy of sonography in our algorithm when differentiating patients with BAT who need immediate surgery from patients who would benefit from further diagnostic workup or who need no treatment. Our algorithm that uses sonography as the primary diagnostic tool provides accurate, fast, cost-effective, and noninvasive initial management of patients with BAT. Sonography also achieves high values in revealing relevant injury. Our algorithm produced medically satisfactory and economically prudent management of patients with BAT.  Handheld US using the Sonosite 180 system can be successfully used by appropriately trained doctors as the primary investigation in the acute evaluation of BAT.  In order to avoid unnecessary laparotomies for patients with BAT, the emphasis is now on early ultrasonic examination of the abdomen in combined trauma. The radiological evaluation of patients with BAT can be done with either US or CT with strategies varying considerably among institutions.
FAST is an US investigation that can discover the presence of peritoneal fluid. The availability of an investigation that can be used directly at the patient bed optimizes the Emergency Room Service. The learning curve is short  and all doctors working in Emergency Room can use it. Patients underwent complete US examination, including free fluid search and solid organ analysis. No diagnostic test beats a good history and careful examination  USS has proved to be a thoroughly reliable, , cost efficient, and noninvasive modality in primary evaluation and follow-up of BAT. US is highly sensitive for the detection of free intraperitoneal fluid  but not specific in identification of organ injuries. Other factors affecting the sensitivity were type of USS machine, the experience of sonographer, the size of the patient (obesity, abdominal distention). In hemodynamically stable patients, the value of US is mainly limited by the large percentage of organ injuries that are not associated with free fluid. A large intraperitoneal  fluid accumulation on USS in combination with unstable vital signs is sensitive for determining the need for exploratory laparotomy in patients presenting with blunt trauma. Because of its high negative predictive value, we recommend that clinical follow up is adequate for patients whose US results are negative for intra-abdomial organ injury.
| Conclusion|| |
Ultrasonography is accurate for screening patients with blunt abdominal trauma in a tertiary institution. It is cheap and can be performed in the emergency department of hospital. It has high sensitivity and specificity. It is the method of first choice in the evaluation of blunt abdominal trauma.
| References|| |
|1.||Kristensen JK, Buemann B, Kuhl E. Ultrasonic scanning in the diagnosis of splenic haematomas. Acta Chir Scand 1971;137:653-7. |
|2.||Kretschmer KH, Bohndorf K, Pohlenz O. The role of sonography in abdominal trauma: The European experience. Emerg Radiol 1997;2:62-7. |
|3.||Yoshii H, Sato M, Yamamoto S, Motegi M, Okusawa S, Kitano M, et al. Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma 1998;45:45-51. |
|4.||Healy MA, Simons RK, Winchell RJ, Gosink BB, Casola G, Steele JT, et al. A prospective evaluation of abdominal ultrasound in blunt abdominal trauma: Is it useful? J Trauma 1996;40:875-83. |
|5.||Soffer D, Schulman CI, McKenney MG, Cohn S, Renaud NA, Namias N, et al. What does ultrasonography miss in blunt trauma patients with a low Glasgow Coma Score (GCS)? J Trauma 2006;60:1184-8. |
|6.||Hoffmann R, Nerlich M, Muggia-Sullam M, Pohlemann T, Wippermann B, Regel G, et al. Blunt abdominal trauma in cases of multiple trauma evaluated by ultrasonography: A prospective analysis of 291 patients. J Trauma 1992;32:452-8. |
|7.||Nural MS, Yardan T, Guven H, Baydin A, Bayrak IK, Kati C. Diagnostic value ofultrasonography in the evaluation of blunt abdominal trauma. Diagn Interv Radiol 2005;11:41-4. |
|8.||Brown MA, Sirlin CB, Hoyt DB, Casola G. Screening ultrasound in blunt abdominal trauma. J Intensive Care Med 2003;18:253-60. |
|9.||Buzio M, Bertello A, Bau G, Mao P. (Ultrasound in trauma (FAST)). Minerva Chir 2000;55:89-95. |
|10.||Soyuncu S, Cete Y, Bozan H, Kartal M, Akyol AJ. Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma. Injury 2007;38:564-9. |
|11.||Baque P, Iannelli A, Dausse F, de PF, Bourgeon A. A new method to approach exact hemoperitoneum volume in a splenic trauma model using ultrasonography. Surg Radiol Anat 2005;27:249-53. |
|12.||Benelli G, Bonardi R, Parziale M, Campari PF. (Role of echography in the differential diagnosis of accessory lobulations and small capsular traumatic fissures of the spleen). Radiol Med 1992;84:770-3. |
|13.||Benya EC, Lim-Dunham JE, Landrum O, Statter M. Abdominal sonography in examination of children with blunt abdominal trauma. AJR Am J Roentgenol 2000;174:1613-6. |
|14.||Klingler PJ, Wetscher G, Glaser K, Tschmelitsch J, Schmid T, Hinder RA. The use of ultrasound to differentiate rectus sheath hematoma from other acute abdominal disorders. Surg Endosc 1999;13:1129-34. |
|15.||Lucciarini P, Ofner D, Weber F, Lungenschmid D. Ultrasonography in the initial evaluation and follow-up of blunt abdominal injury. Surgery 1993;114:506-12. |
|16.||Givre S, Kessler S. The evaluation of blunt abdominal trauma: The evolving role of ultrasound. Mt Sinai J Med 1997;64:311-5. |
|17.||Bode PJ, Edwards MJ, Kruit MC, van Vugt AB. Sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma. AJR Am J Roentgenol 1999;172:905-11. |
|18.||Brooks A, Davies B, Connolly J. Prospective evaluation of handheld ultrasound in the diagnosis of blunt abdominal trauma. J R Army Med Corps 2002;148:19-21. |
|19.||Catalano O, Aiani L, Barozzi L, Bokor D, De MA, Faletti C, et al. CEUS in abdominal trauma: Multi-center study. Abdom Imaging 2009;34:225-34. |
|20.||Chambers JA, Pilbrow WJ. Ultrasound in abdominal trauma: An alternative to peritoneal lavage. Arch Emerg Med 1988;5:26-33. |
|21.||Bode PJ, Niezen RA, van Vugt AB, Schipper J. Abdominal ultrasound as a reliable indicator for conclusive laparotomy in blunt abdominal trauma. J Trauma 1993;34:27-31. |
|22.||Ma OJ, Kefer MP, Stevison KF, Mateer JR. Operative versus nonoperative management of blunt abdominal trauma: Role of ultrasound-measured intraperitoneal fluid levels. Am J Emerg Med 2001;19:284-6. |
|23.||McElveen TS, Collin GR. The role of ultrasonography in blunt abdominal trauma: A prospective study. Am Surg 1997;63:184-8. |
|24.||Cardi F, Bucceri A, Petralia G, Catalano F, Catania G. (Role of ultrasonography in abdominal surgical emergencies. Our experience). Ann Ital Chir 1996;67:61-4. |
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]